from bismarck and beveridge to · 2013-05-27 · from bismarck and beveridge to «bisridge » type:...

From Bismarck and Beveridge to « Bisridge » type: developments and« Bisridge » type: developments and convergence in EU health systems

h d f d

g y

Reinhard Busse, Prof. Dr. med. MPH FFPHDept. Health Care Management, Technische Universität Berlin, Germany

(WHO Collaborating Centre for Health Systems Research and Management)(WHO Collaborating Centre for Health Systems Research and Management)&

European Observatory on Health Systems and Policies

Third party PayerThird-party Payer

ProvidersPopulation

Third party payerCollector of Third-party payerCollector of resources

Steward/regulator

ProvidersPopulation

Back in 1993, the EU world was nicely dividedinto NHS and SHI (with two difficult outliers)into NHS and SHI (with two difficult outliers)

SHISHINHS

NHS

SHI

SHI

SHISHI

NHSNHSNHS

Classical integrated NHS-type systemCentral

government (MoF)

Central government

(MoH)(MoF) (MoH)

General NHS =payer &taxation payer &provider

Population Public providersLimited h iUniversal

coveragechoice

Development 1Central

government (MoF)

Central government

(MoH)(MoF) (MoH)

General Purchaser –

providertaxation

providersplit

Public providersLimited h i

PopulationchoiceUniversal

coverage


government (MoF)

Central government

(MoH)(MoF) (MoH)


providertaxation

providersplit

Limitedh i

Public providersPopulationmore choice

(moneyUniversalcoverage

follows patient)


government (MoF)

Central government

(MoH)(MoF) (MoH)

Purchaser –providerGeneral provider

splittaxation

Public “autonomous”

Limitedh i

Population autonomousprovidersmore choiceUniversal

coverage


government (MoF)

Central government

(MoH)(MoF) (MoH)


providersplittaxation split

Public “autonomous”

Limitedh i

Population autonomousprovidersmore choiceUniversal

coverage

Development 5Central Regional

governments ( h l d d t li d

Central government

(MoF) (where already decentralized larger units)

(MoF)


providersplittaxation split

Limitedh i

Public “autonomous”Population

more choice autonomousprovidersUniversal

coverage

Development 5Central Regional

governmentsCentral

government (MoF)

Questions arising:F di f ti l i l t ti ?

(MoF)

Purchaser –providerGeneral

• Funding from national or regional taxation?• Benefit catalogue uniform?

S l d it d lit l t d if l ?providersplittaxation• Supply density and quality regulated uniformly?

• Access to services across regional borders?

Limitedh i



coverage

Development 6Regional

governmentsCentral

government (MoF)(MoF)

Purchaser –provider

splitGeneral

Steward/ splittaxation Steward/regulator (MoH)

Limitedh i



coverage

Development 6Regional

governmentsCentral

government (MoF)(MoF)


providersplitSteward/taxation splitSteward/

regulator (MoH)

Limitedh i

Public “autonomous”Populationmore choice and private

providersUniversalcoverage

Where are the differences to SHI systems?Collector of

Sickness funds(professionally defined

Collector of resources

Wage-relatedC t t &

membership)

contributions Contracts & FFS/per-diems

Steward/Steward/regulator (MoH)

Ch i iProvidersPopulationPublic-private mixChoice in

accessCoverage of

(ex-)employees

1993

Collector ofCollector of resources (group 1: in competition/

Sickness fundsgroup 2:

on regional basis)Wage-relatedC t t(group 1: selective)& Cap /FFS/DRGsSteward/

+ taxescontributions Contracts

& Cap./FFS/DRGsSteward/regulator (MoH)

ProvidersGuidedPopulationCh i iUniversal

coveragePublic-private mixChoice in

access

2013

Today, the EU world can no longer be nicelydivided into NHS and SHI “Bisridge”

rNHS

rNHS SHI

SHI

cSHIcSHI

rNHS

rNHS

rSHI

SHI

cSHI

rSHI

SHISHI cSHI

cSHIrSHI SHI rSHI

NHS

rNHSrNHSSHI

rNHS

Was the (enlarging) EU the driver?

2003: High Level process of reflection on patient mobility and healthcare2003: High Level process of reflection on patient mobility and healthcaredevelopments in the EU

2004: High Level Group on Health Services and Medical care2006: Removal of health services from the Directive on Services in the2006: Removal of health services from the Directive on Services in the

Internal Market2006: Council conclusions on Common values and principles in EU Health Systems2006 07: Public consultation on Community action on health services2006-07: Public consultation on Community action on health services2008: European Commission proposal for a Directive on the application

of patients’ rights in cross-border health care2009 E P li t’ fi t di2009: European Parliament’s first readingMay 2010: Implementation of the revised social security coordination framework

(EC Regulation 883/2004 and Regulation 987/2009)J 2010 C il' f EU i i t h itiJune 2010: Council's of EU ministers reach a common positionNov 2010: European Parliament’s Report, 2nd readingJan 2011: European Parliament plenary sitting, 2nd reading 9 March 2011: Directive passed25 Oct 2013: Deadline for transposition into national law

Not directly: but besides the official EU health policywhich acknowledged health systems quite late

2003: High Level process of reflection on patient mobility and healthcare

which acknowledged health systems quite late,countries were eager to learn from each other

2003: High Level process of reflection on patient mobility and healthcaredevelopments in the EU

2004: High Level Group on Health Services and Medical care2006: Removal of health services from the Directive on Services in the2006: Removal of health services from the Directive on Services in the

Internal Market2006: Council conclusions on Common values and principles in EU Health Systems2006 07: Public consultation on Community action on health services2006-07: Public consultation on Community action on health services2008: European Commission proposal for a Directive on the application

of patients’ rights in cross-border health care2009 E P li t’ fi t di2009: European Parliament’s first readingMay 2010: Implementation of the revised social security coordination framework

(EC Regulation 883/2004 and Regulation 987/2009)J 2010 C il' f EU i i t h itiJune 2010: Council's of EU ministers reach a common positionNov 2010: European Parliament’s Report, 2nd readingJan 2011: European Parliament plenary sitting, 2nd reading 9 March 2011: Directive passed25 Oct 2013: Deadline for transposition into national law

Common challenges …

fi i l h i fragmentedageingfinancial

crisischronic

disease ↑fragmentedhealth caredelivery

financial resourcesfor health care ↓

variation/

expenditure/ costs ↑

variation/ unnecessary care

gap

lowproductivity

… answers …


crisischronic



variation/

effectiveprevention

carecoordination/



gap and carecoordination/integration

newtechnologies

lowproductivity

qualityof care delivery

evidence‐b d

efficiency of provision ↑

value‐for‐money

deliverybasedmedicineadditional

resourcesresources

… and instruments


crisischronic



variation/

effectiveprevention

carecoordination/




newtechnologies

lowproductivity


evidence‐b d

value‐for‐money

deliverybasedmedicineefficiency of

provision ↑additionalresources

clinicalguidelines/

paying bycapitation

HealthTechnology

measuring &rewarding

e.g. new rolesfor health

resources

cost‐sharing ↑

DMPs& DRGs Assessment quality (P4P) professionals(???)

…, limited/driven by values


crisischronic



variation/

effectiveprevention

carecoordination/




newtechnologies

lowproductivity


evidence‐b d

value‐for‐money

deliverybasedmedicineefficiency of

provision ↑additionalresources

clinicalguidelines/

paying bycapitation

HealthTechnology

measuring &rewarding

e.g. new rolesfor health

resources

cost‐sharing ↑

DMPs& DRGs Assessment quality (P4P) professionals(???)

Universality, access to good quality care, equality, solidarity

And where do policy‐makers learn about these things?

Access to high quality health care (taken a population perspective) – where are we? p p )

Measured by “Avoidable mortality”Deaths per 100,000 population*

134 127

120

150 1997–98 2006–07

Deaths per 100,000 population

88 89 8899 97

109 116

106 97

115 113 120

100

76 88 89

81 88

55 57 60 61 61 64 66 67 74 76 77 78 79 80 83 96 50

55

0 FR AUS ITA JPN SWE NOR NETH AUT FIN GER GRE IRL NZ DEN UK USFR AUS ITA JPN SWE NOR NETH AUT FIN GER GRE IRL NZ DEN UK US

And what do our populations say? Are they satisfied with health care? Positive answers in EU15 countries (in %) 1996 2011; sorted by result in 2009Positive answers in EU15 countries (in %), 1996‐2011; sorted by result in 2009

Health‐care inCountry’s health‐care system care in city or area

1996 1998 1998 1999 2002 2004 2007 2008 2008 2009 2010 2011 2008Belgium 70 63 57 77 65 88 97 91Austria 63 73 71 83 67 84 95 93Finland 86 81 78 74 73 85 94 66F 65 65 59 78 64 65 23 83 91 42 40 83France 65 65 59 78 64 65 23 83 91 42 40 83Netherl. 73 70 70 73 46 42 77 91 51 46 89Sweden 67 58 46 59 48 79 90 44 40 77Luxembg. 71 67 50 72 58 90 88 90gDenmark 90 91 48 76 52 77 87 86UK 48 57 49 56 31 32 26 17 73 86 62 51 85Germany 66 58 43 50 47 28 20 20 54 86 38 32 87Spain 36 43 31 38 46 42 37 77 81 74Spain 36 43 31 38 46 42 37 77 81 74Italy 16 20 15 26 31 21 13 53 54 57Ireland 50 58 23 48 20 40 53 64Portugal 20 16 6 24 14 58 42 64Greece 18 16 11 19 19 45 25 52

Very/ fairly satisfied System works pretty well Satisfied 7‐10/10 Confidence in national system Quality good

Presentation available at:

www.mig.tu‐berlin.de

www healthobservatory euwww.healthobservatory.eu

from bismarck and beveridge to · 2013-05-27 · from bismarck and beveridge to «bisridge » type:...

Documents